The care-home environment is a tricky one for the safety and health practitioner, not least because of how the concept of risk sits with aims of ensuring independence and dignity for a vulnerable group of people. Tony Kelly offers some advice for professionals in this sector.
The majority of care homes in the UK are well run and embody high standards of care. Indeed, the only time we tend to hear about care homes in the media is when something has gone wrong, which reflects the safety-critical nature of the caring professions.
Care homes for older adults are complicated in that they are many things: a home for those who live there; a place of work for those employed there; and highly-regulated domains for those who manage them. While independence, dignity and choice are commonly-expressed aims of care-home life, both the regulatory state and general public concern can have a significant impact on these ideals.
So, how does this juxtaposition of home and work impact on both the home and the safety practitioner?
Market reform
Over the last two decades there has been a shift in emphasis from ‘welfare’ to ‘consumerism’ in social care.1
In 1979, the Conservative government drew what has been described as “a dividing line in the history of residential care for older people”.2 From this point, local-authority residential homes began to lose their dominant position, as policy-makers gradually divested the public sector of its provider functions, believing that the move to a market would ultimately drive out poor-quality services. Unfortunately, this has not entirely proved to be the case, leading to political demands for increasingly rigorous forms of public scrutiny.
Since 1997, the Labour government has introduced a series of reforms. The 1998 ‘Modernising Social Services’ White Paper proposed an improved inspection and regulatory regime, The Care Standards Act.
This replaced the Registered Homes Act 1984 where local authorities registered and inspected residential homes, including their own, and local health authorities performed a similar function for nursing homes.
In 2003, The Health and Social Care (Community Health and Standards) Act created the Commission for Social Care Inspection (CSCI), which has taken over national responsibility for the registration and inspection of all care homes, and care homes ‘with nursing’.
Homes are now inspected and assessed against National Minimum Standards (NMS), published by the Health Secretary, and designed to ‘guarantee the public interest, even while ownership remains outside the public sector’.3 Standard 38 of these NMS effectively requires care-home managers to comply in full with all aspects of UK health and safety law.
In line with the Hampton report’s principles for better regulation,4 the HSE, the Local Authorities’ Coordinators of Regulatory Services (LACORS), and the CSCI recognised that a Memorandum of Understanding (MoU) was required to effectively target and coordinate the effective enforcement of health and safety law. The MoU established a ‘dichotomy’ of risk management whereby the CSCI would target resident-related risk, leaving premises and staff-related risk to the local EHO, or HSE inspector.
The existence of Standard 38 in no way diminishes the roles and responsibilities of the local-authority environmental health officers, or the HSE, whose role is to enforce the Health and Safety at Work, etc. Act 1974 and its associated regulatory framework.
However, one might speculate that the dichotomy set up by the MoU has created confusion at an operational level, perhaps reflected in the comments of one coroner who, in 2006, criticised a care home’s failure to correlate person and premises-related risk assessments.5
The MoU has now been removed from the Internet, as the HSE has recognised that it no longer accurately reflects the role of the CSCI and, perhaps, also acknowledging that such a dichotomy is indeed too simplistic.
Further reflection came about in 2005 when the HSE, LACORS and the CSCI established a ‘Risk and Safety in Social Care Project Board’ (RSSCPB). Its remit was to “promote sensible risk management in the social-care sector, which strikes the right balance between enabling adults and children who use care services to lead independent and dignified lives, and the need to avoid and prevent unnecessary harm to them and their carers”.
At the time of writing, the CSCI’s future is somewhat in doubt, however, as a result of imminent government proposals to create a single independent health and adult social-care regulator for the NHS, the independent sector, and all providers of health and adult social care.
Managing risk
The problem, if one can call it such, is that care homes are meant to be ‘home’ for those who live there. From a sociological perspective, home is a physical and social space in which social interaction takes place. Peace and Holland paint a vivid picture of life at home, where “people can. . . make choices.
They can light a fire, re-heat yesterday’s dinner, re-decorate a room, or dig up the garden”.6 They may not expect someone from outside the home to tell them how to do these things. While this ‘definition’ of home will resonate with most people, in a care-home environment it may also portray images of ‘risk’ and, thereby, the application of health and safety laws.
Risk can be classified into techno-scientific and socio-cultural paradigms.7 The techno-scientific paradigm is most closely associated with the legal imperative to identify potentially harmful work activities.
In a residential home this will include all aspects of the building and the care and management practices that take place within it. Techno-scientific risks include those subject to management control, including risks from: gas and electrical appliances, chemicals, falling from height, scalding, and burning.
The socio-cultural management of risk is perhaps more elusive. Beck suggests that society has a problem with notions of risk, whereby “insurance experts contradict safety engineers. . . Politicians encounter the resistance of citizens’ groups”.8 In this way, risks deemed a normal part of everyday adult life, such as doing one’s own laundry, may become ‘unacceptable’ within the highly-regulated environment of residential care.
Conversely, the well-drafted laws protecting the world of work might be inadvertently translated in ways that emphasise the physical aspects of care associated with the less than homely values of institutions. As a result, homely values might fall second to a preoccupation with avoiding risk,9 and laws drafted with supportive intentions in mind may become controlling, in effect.10
In care homes, such controlling effects might manifest themselves in the following recognisable ways: residents are not allowed into the kitchen or laundry; bathwater temperatures are controlled so they cannot surpass 43°C; and bedroom windows are restricted so that they cannot be fully opened.
It would be grossly unrealistic to diminish the potential for harm that failure to address such measures can bring, or to suggest that all care homes apply all of these measures. However, readers should imagine for a moment that they are living in such a home, and perhaps contemplate how they might feel if their choice was limited by extensive risk-management measures.
Compliance or ritual?
There is another interesting paradox here — while homes might apply the ‘higher-profile’ control measures just described, serious, and often avoidable, accidents continue to occur to both staff and residents.
The major problem is not necessarily resistance to applying health and safety regulation but what has been described as ‘ritualism’, the act of going along with institutionalised means to achieve regulatory goals despite not attaining the goals themselves.11
A good example of this is the issue of glass, glazing, and falls from height. In such cases, the home might have installed window restrictors on all of its first-floor windows, but have they also assessed the risks presented by the glazing panels themselves?
Some local-authority environmental health departments offer online guidance to care homes that glass should “conform to BS6262, and be marked so that people are made aware of the presence of glazed areas”. Yet, how many homes have actually implemented this advice — what about glass tables, cabinets, or even fish tanks?
Such rituals may extend to the documented systems that the regulatory system requires care homes to maintain. It is at this interface that safety practitioners may become involved in designing written systems for the home; undertaking risk assessments, drafting policies, and writing procedures that in some instances may never be implemented in the manner intended by the safety practitioner. The documented system may therefore become a means to ‘demonstrate compliance’ while not necessarily delivering safe or intended outcomes.
It is important to acknowledge and to recognise that ‘ritualism’, in the sense just described, is not necessarily a conscious or deliberate act of omission on the part of the home manager. Safe systems might have been written in isolation from the systems controlling ‘care’, and, as a result, there may be conflicts in terms of how different policies and procedures reflect the same areas in the home.
For example, does the home’s laundry and cleaning procedures reflect the control of substances hazardous to health by combining and reflecting the risk assessments for body fluids and the control measures that staff are supposed to take?; do such procedures cross-reference other key documents, such as those controlling plans of care for individual residents and, importantly, communication and training for all staff?
Making a difference
Safety practitioners can make a real difference by working with care homes to develop solutions, which, while ensuring legal compliance, also maintain choice and homely values. This may involve the practitioner developing an appreciation of the socio-cultural aspects of risk management from the perspective of those who must live and work in care homes for older adults.
‘Off-the-peg’ safety solutions, where the only difference between any two homes is the name on the front cover, are unlikely to achieve their stated objectives. Ideally, the home’s manager, staff and residents will set the vision for the type of home that they want to live and work in, and the safety practitioner will advise, guide, facilitate, de-mystify, support, and contribute to realising this vision.
Support is perhaps the most important aspect of this relationship — often ‘institutional’ controls can be easier than ‘sensible risk-taking’ measures, and it may well be the safety practitioner who has to argue this case with those who see any form of risk as irresponsible.
References
1 Allen, I (1992): Elderly people: Choice, participation and satisfaction, Policy Studies Institute, (London)
2 Peace, S and Katz, J (eds.): (2003), End of life in care homes: A palliative care approach, Oxford University Press, (Oxford)
3 Drakeford, M (2006): ‘Ownership, regulation and the public interest: The case of residential care for older people’, in Critical Social Policy, vol. 26(4): 932-944
4 Hampton, P (2005): Reducing administrative burdens: Effective inspection and enforcement. Report by HM Treasury, March 2005
5 Nottingham Evening Post, (2006): ‘Son’s anger. . . two falls in two weeks’, 7 August 2006
6 Peace, S and Holland, C (2001): ‘Homely residential care: A contradiction in terms?’ in Journal of Social Policy, 30, 3, 393—410, Cambridge University Press
7 Lupton, D (1999): Risk, Routledge, (London)
8 Beck, U (1994): ‘The reinvention of politics: Towards a theory of reflexive modernisation’, in Beck, U, Giddens, A, and Lash, S (eds.): Reflexive Modernisation, Polity (Cambridge)
9 Bland, R (2005): ‘Senior citizens, good practice and quality of life in residential care homes’, PhD thesis, Stirling University
10 Burton, J, (2005): ‘The case for collaboration’, Caring Times, Mar 2005, p18, Hawker Publications, (London) available at www.careinfo.org
11 Braithwaite, J (1993): ‘The nursing home industry’, in Tonry, M and Reiss, AJ (eds.): Beyond the law: Crime in complex organisations, Crime and Justice, Vol. 18, pp11-54
Tony Kelly is a registered nurse and chartered safety practitioner.
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